Provider Demographics
NPI:1396235974
Name:VASQUEZ, MAYRA ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:ELIZABETH
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4113 WELLINGTON WOODS CIR APT 107
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2747
Mailing Address - Country:US
Mailing Address - Phone:407-569-5473
Mailing Address - Fax:
Practice Address - Street 1:4898 E IRLO BRONSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34771-8714
Practice Address - Country:US
Practice Address - Phone:407-891-3091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV220-545-76-925-0OtherDRIVER'S LICENSE